Content uploaded by Andrey Bychkov
Author content
All content in this area was uploaded by Andrey Bychkov on Feb 23, 2023
Content may be subject to copyright.
C O N S TA N T
DEMAND,
PAT C H Y
SUPPLY
The first
comprehensive
study on the global
pathologist workforce
both identifies key
disparities in pathologist
supply and prepares the
ground for correcting
these imbalances
By Andrey Bychkov and Michael Schubert
20 Feature
20 Feature
www.thepathologist.com
2
Pathologists Per Million
= >40
= 30–39
= 20–29
= 10–19
= 1–9
= <1
A World Map of Pathologist Density
Feature 21
2
Pathologists Per Million
= >40
= 30–39
= 20–29
= 10–19
= 1–9
= <1
An ever-increasing workload and an insufficiency of
pathologists; it’s an old story and we know it well. At least,
we think we do – but how many of us know the actual numbers
behind this received wisdom? And does the numerical
imbalance stay the same from region to region, country to
country? e truth is, nobody has ever dened the details of
this broadly appreciated, but vaguely understood, narrative of
the shortfall in trained pathologists – until now, that is.
is groundbreaking map represents the rst-ever attempt
at a global quantication of pathologist numbers: over 108,000
individuals in 162 countries and territories, representing about
98.5 percent of the world’s population (data collected in 2019–
2022 by Andrey Bychkov). It also reveals glaring disparities;
the mean number of pathologists per million population is
14, but people in the United States enjoy 65 pathologists per
million, whereas those in Africa have access to, on average,
fewer than three pathologists per million. e 10 countries
with the highest number of pathologists account for over
two-thirds of the total pathologist workforce worldwide – a
list is topped by the US, India, China, Iran, and the UK.
Worldwide, the WHO estimates the number of medical
doctors at approximately 13.2 million, indicating that about
one in every 120 doctors (0.8 percent) is a pathologist.
Quantifying the problem in this way is essential, but represents
only part of the value of these data; crucially, they provide a
baseline for future investigation and may help direct personnel
recruitment plans in countries across the globe. In brief, they
represent an essential rst step in correcting the signicant
international imbalances in pathologist supply.
Tell us about your contributions to understanding
the pathology workforce…
Stanley Robboy: During the time I headed the College of
American Pathologists (2009–2013), our board recognized
that American medicine was in a crisis and about to undergo a
massive change. No one knew what form that would take – but,
wanting to be proactive, we embarked on reviewing all aspects
of pathology, including the workforce. I headed that thrust.
e two obvious elements of workforce are supply and
the functions we serve. We now know that the numbers we
established in 2013 (1) were too low, because the Association
of American Medical Colleges (AAMC) ignored pathologists
who subspecialized. What we did correctly identify was the
beginning of the retirement cli, although the name was poor.
It was not a cli, but a gradual slide in which the number of
people entering the profession was consistently lower than the
number retiring. e highest rate of entry was from the 1960s
to the 1980s; after that, the number of retirees overshadowed
Feature
22
22 Feature
22 Feature
www.thepathologist.com
Our Panelists
Stanley Robboy is Professor Emeritus
of Pathology, Duke University,
Durham, North Carolina, USA.
Bruno Märkl is Director of the
Institute for Pathology and Molecular
Diagnostics, University Medical
Center, Augsburg, Germany.
Michael Wilson is Professor and
Vice-Chair at the University
of Colorado Anschutz Medical
Campus, Aurora, and Director of
the Department of Pathology and
Laboratory Services at Denver
Health, Denver, Colorado, USA.
Joshua Kibera is an anatomical
pathologist, Founder and CEO
of e Pathology Network,
Nairobi, Kenya.
René Buesa is retired; formerly
Histotechnologist and Pathology
Laboratory Manager at Mount
Sinai Medical Center of Greater
Miami, Florida, USA.
Ann Nelson is Senior Advisor
and Director of LIS Programs at
Pathologists Overseas, Infectious
Disease Pathology Consultant at
the Joint Pathology Center and
Visiting Professor of Pathology at
Duke University, Durham, North
Carolina, USA.
Mike Osborn is President of the
Royal College of Pathologists and
Consultant Histopathologist for
North West London Pathology at
Imperial College Healthcare NHS
Trust, London, UK.
Andrey Bychkov is Director of
Digital Pathology at Kameda
Medical Center, Kamogawa, Japan.
Feature 23
the number of new pathologists – and has, since 2000, been
stable at about 600 each year.
A subsequent paper in 2015 (2) explored several important
new facets. One was the taxonomy of pathologist activities – the
settings of their work and functions. It became evident that this
taxonomy was much more complex than anyone had previously
conceived – but has proven crucial to developing workforce
projections. A second was our ability to quantitatively project
the demand by subspecialties. is understanding involved more
than simply the numbers of specimens examined annually; it had
to explore the technology needed to examine the specimens,
which improved year on year. We also published
how to measure those changes (3).
We are currently working with the
AAMC to better understand the
outdated methodology it used
to provide workforce numbers
for pathology and, I suspect,
for all medical specialties.
Our rst joint publication is
expected to emerge shortly.
Bruno Märkl: Wonderi ng
why it was so difficult
to hire board-certified
pathologists in Germany, I
started to collect data such
as total numbers of working
pathologists, numbers of
physicians in training, gender
proportions, and so on. I discussed
my insights with colleagues who
encouraged me to publish – so I
validated my data and compared the
German results with numbers in other European
countries and in North America (4).
Michael Wilson : Most of my work was on a pathology workforce
survey via the group African Strategies for Advancing Pathology
(ASAP) (5), the Lancet series on pathology and laboratory
medicine in low-income and middle-income countries, (6),
and most recently the Lancet Commission on diagnostics (7).
Joshua Kibera: I am an anatomical pathologist and have
practiced for eight years in Kenya. I spent four years as Head
of Department at the Kenya Methodist University, then
established my own anatomical pathology lab in 2017, which
later merged with a cancer center servicing the Kenyan town of
Meru and its environs. I have traveled to and been involved with
pathologists in South Africa, Uganda, Botswana, Tanzania,
Ethiopia, Somalia, Zambia and Kenya, so I am familiar with
workforce challenges in sub-Saharan Africa.
Rene Buesa: From my arrival to the USA (from Cuba) in 1983
until my retirement in 2002, I worked rst as histotechnologist,
then as pathology laboratory manager. In that time, I made
a number of contributions to the eld in terms of safety and
eciency. After my retirement, I decided to share my managerial
experience – which included running numerous surveys to
determine workloads, stang benchmarks, turnaround times,
and productivity gures for every histology and cytology
position and task in the USA and multiple other countries.
Ann Nelson: I have worked in pathology development in
Africa since 1986 – I set up the rst AIDS pathology
lab in Kinshasa, Zaire. I have collaborated with
Association of Pathologists of East, Central
and Southern Africa (APECSA), the
International Academy of Pathology,
and other organizations to increase
pathology capacity and utilization
in Africa. With colleagues, we
did a comprehensive survey
of anatomic pathology
workforce and capacity (8).
I have also collaborated
with and mentored many
pathology leaders in sub-
Saharan Africa.
Mike Osborn: e College
has repeatedly raised the issue
of workforce shortages across
pathology services with the UK
government and devolved nations’
administrations. We achieve this
by attending parliamentary meetings,
submitting responses and evidence to
parliamentary groups, brieng parliamentarians
to raise awareness of pathology, asking them to raise issues
in parliament and with government on behalf of the profession,
and responding to government consultations. In addition, we
are closely involved with a range of other organizations directly
and indirectly involved in workforce planning and resourcing.
e groups consist primarily of high-level National Health
Service (NHS) committees and other relevant stakeholder
groups, but the College will work with any suitable stakeholder
to highlight workforce issues and try to resolve them.
Issues raised have included calling for suciently trained
sta, including increased numbers of biomedical scientists
supporting medically qualied pathologists in integrated teams
to achieve maximum productivity; improving retention of
consultants and lab sta (having the right number of diagnostic
sta in the right places, working in a supportive culture, is
24 Feature
24 Feature
www.thepathologist.com
key to the delivery of an agile and resilient pathology service
with patients at its heart); and building resilience in workforce
by ensuring that stang levels are sucient to meet service
expectations. is is not possible where stang is aimed at
covering minimum or average workloads.
Do you think the map accurately reflects
pathology’s status in your region?
Andrey Bychkov: Data was collected from national registries
with the assistance of local pathologists, international and local
journal publications, and communication with local societies.
e information was veried through personal
communication with pathologists from the
respective countries whenever possible.
After validation, the data were
classied as reliable, acceptable, or
questionable, with questionable
data excluded from the nal
analysis. All subspecialties
were included, but residents
and trainees were excluded.
SR: It is dicult for me
to say whether it is high,
correct, or low; at best, I
can say it works. However,
even though we are now
seeing the rise of automation
and articial intelligence,
there is little question that
the incoming supply of US
pathologists in the years to come
will remain less than those retiring.
For many years, pathology graduates
could not nd jobs. Suddenly, over this past
year, I now continuously see the number of open
positions far exceeding anything experienced for decades.
Currently, there is an insucient workforce – but we don’t
control residency slots, so it is dicult to make predictions.
BM: Yes, the map appears accurate for my region.
MW: Yes, but the challenge is that workforce data are
largely lacking for many regions – particularly in areas such
as sub-Saharan Africa, where there are no formal registries
or databases in most countries.
JK: For sub-Saharan A frica, the data appear more or less correct.
AN: e data include anatomic and clinical pathology,
disciplines that are not combined in much of Africa – but the
relative numbers seem correct.
MO: e heat map appears to show that there are enough
pathologists in the UK – but this was not the case
even before COVID-19 and the associated backlog
and the situation has worsened since the pandemic.
In addition, there are signicant variations between
regions and specialties. Northern Ireland, for
example, currently has no pediatric consultant
pathologists, and many rural locations across UK face
greater workforce pressure with pathologist recruitment
and retention than more urban centers.
AB: e UK data include not only histopathologists – also
known as surgical or anatomic pathologists (AP) – but also other
subspecialties, such as clinical pathologists (CP), microbiologists,
chemical pathologists, and so on. e AP:CP ratio
in the UK is 1.5:1, which is ve to 10 times
lower than in countries that don’t use the
British system of pathology education
and nomenclature. Furthermore, in
many European countries, CP-
equivalent jobs are occupied
by other specialties, such as
medical laboratory scientists,
who are not pathologists
and sometimes not even
medical doctors. e UK
has a histopathologist
density of 23 per million
people (a shortage; this
would be yellow on the
map). Projecting to the global
level, my estimation would be
that out of 108,000 practicing
pathologists, only about 90,000 to
100,000 are surgical pathologists.
It’s important to add that our
data don’t include residents or trainees,
who perform a signicant amount of work in
pathology labs, but who are not board-certied. e number
of residents varies widely by country, from less than 10 percent
to up to 50 percent of all pathologists. For example, the USA
oers a xed number of just over 600 pathology residency slots
each year, whereas India has recently raised that number to
2,350. I predict that, in just a few years, India will top the list.
What does the pathology workload and pipeline
look like in your region?
SR: e workload for individual pathologists has increased
over the years and I’m concerned about the dangers inherent
in the rise.
“ F O R
MANY YEARS,
P A T H O L O G Y
G R A D U A T E S C O U L D
NOT FIND JOBS.
SUDDENLY [...] THE
NUMBER OF OPEN
P O S I T I O N S F A R
EXCEEDS ANYTHING
EXPERIENCED FOR
DECADES.”
Feature 25
In the early 1970s, a committee I headed for the Massachusetts
Society of Pathologists specically addressed workload numbers.
e number we felt comfortable for an average pathologist at a
secondary or tertiary center to handle annually was about 2,500
(one or two highly involved operations per day; three or four
larger specimens; the rest biopsies). I now hear that pathologists
commonly are expected to examine over 4,000 – sometimes
considerably more – cases a year. at means the time per case
becomes unbearably short, which I fear will lead to burnout and
errors. A study we recently published reports that burnout rates
for people with more than three years in practice have jumped
signicantly (9). is occurred whether or not the person was
anxious or experienced burnout in residency. Burnout is now
becoming the norm and I attribute this to unhealthy workloads.
BM: In Germany, we maintain the number of working
pathologists. However, the rate of part-time workers is growing
while full time equivalents are decreasing. I have no validated
data concerning workload, but I estimate that the average
number of cases per pathologist per year is around 10,000.
MW: e situation in most of Africa is woefully inadequate;
the number of pathologists per population is a small fraction of
what is needed to deliver necessary services at a population level.
e average workload of a pathologist is highly variable, but
in general low (except in some urban areas) due to inadequate
healthcare systems, funding, and infrastructure – and a lack
of awareness of the importance of diagnostics.
JK: Africa is a large continent whose dierent countries
have operated in silos for historical reasons. Sadly, these silos
extend into medical practice, where there is generally very
little professional interaction between practitioners across
the continent. Regional professional bodies have grown in
strength over the last two decades because of geopolitical and
economic unions such as the Southern African Development
Community, the Economic Community of West African
States, and the East African Community. APECSA has been
instrumental in strengthening bonds between pathologists
across the eastern and southern parts of Africa. Multinational
pathology laboratory chains have played a role in elevating
the status of pathology and further cementing relationships
between pathologists in these regions. I am most familiar with
eastern and, to some extent, southern Africa, so my opinions
and observations are limited to these regions.
at said, there is a severe shortage of pathologists in
East Africa (Rwanda, Burundi, Tanzania, Uganda, Kenya
and Somalia) and across southern Africa. ere is currently
relatively free movement of medical professionals across East
Africa – a region that contains 200 million people served by
just 300 pathologists. Training in East Africa tends to focus on
creating general pathologists who can serve as administrators
and practitioners in remote government hospitals. It’s expected
that over half of these pathologists’ work will be in forensic
pathology, so training is heavily oriented toward forensic
pathology, hematology, and microbiology – the laboratory
disciplines expected to make up the bulk of practice.
Most pathologists in eastern and southern Africa hold two or
three jobs and are very busy. ey often shy away from surgical
pathology because of its sensitivity and because their training
generally gives them limited exposure to histopathology. In
Kenya and Uganda, most surgical pathology work is done by
pathologists in the private sector or shipped abroad. Many
www.thepathologist.com
Feature
26
surgeons consider it a luxury, so – in my estimation – 80
percent of samples are either not collected or are thrown away,
even in Kenya (where surgical pathology uptake is highest).
RB: e USA averages are adequate, but pathologists are
retiring and new MDs prefer better-paid specialties, so it is
very likely that, by 2040, there will be shortages. In Cuba in
2020, there were 400 pathologists working in 110 departments
across the country, along with 500 cytotechnicians and
cytopathologists. e only workload information available
was a total of 366,285 autopsies from 1991 to 2002, for an
average of 30,524 per year and 3,330 per site.
Ocial US government statistics say that, in 2019, there
were 21,292 active pathologists and 171,400 histotechnologists
working in 9,111 histopathology and 3,995 cytology laboratories.
e number of pathologists increased 13 percent from 2011 to
2019; histotechnologists are expected to increase 12 percent from
2016 to 2026. In 2011, there were 621,811 tests completed in those
labs for an average workload of 68,248 tests per lab. Pathologists in
the USA have a median of 3,000 cases per year; in Latin America,
excluding Cuba, the mean is 2,100 cases per year.
AN: e pathology workforce has increased signicantly in the
past decade and there are more trainees, but there is still a decit.
MO: ough there is variability across the 17 pathology
specialties that the Col lege covers, pathologists in genera l face great
pressures through rising workloads and the increasing complexity
of their work. Vacancies are also currently 10–12 percent and rising.
e signicant pressure on laboratory sta aects turnaround
times for results, particularly in less automated specialties such as
histopathology, a discipline in which requests to laboratories have
increased by around 4.5 percent year on year since 2007.
ough some specialties are relatively stable when it comes
to workforce, others are facing acute shortages – for example,
pediatric pathology, with 24 consultant vacancies across the
UK – creating considerable pressures on the service.
What future challenges do you anticipate in
staffing and recruitment?
SR: Each sta member means a signicant expense, and with
reimbursements consistently dropping, all CEOs of hospitals
and hospital chains will endeavor to prune payroll. If a national
laboratory can do the same work at 75 percent of the in-house
cost, why wouldn’t CEOs outsource the lab? Fortunately, many
realize their own pathologists are critical intermediaries when
clinicians need help understanding a patient’s disease, whether
further treatment is needed, or even what expensive laboratory
test should (and should not) be ordered. In-house pathologists
often save hospitals bundles of money with their advice.
BM: I predict a systemic shortage of qualied sta over the
next 10 to 15 years. By my calculations, we would need at least
double the number of residents in training to cope with the
growing workload.
MW: e pipeline for pathologists is small in many countries
and, as a result, we are not even replacing the existing workforce
as pathologists move, retire, or leave the profession. ere
are a few examples of small-scale successes, but the number
of people entering the profession globally is far lower than
necessary to expand the workforce.
JK: ere will be a shortage of lecturers to train medical students
in universities. We are not producing enough pathologists to
ll this gap. ere is already a chronic shortage of clinical and
anatomical pathologists and the pace of training does not match
population growth, increasing cancer testing, or the volume of
surgeons, gynecologists, and endoscopists being trained.
RB: Unfortunately, my surveys don’t indicate the numbers
of pathologists or supporting personnel needed per site or
position. Without that knowledge, it is impossible to foresee
future stang and recruitment challenges, let alone the steps
needed to address them locally or globally. We also cannot see
Feature 27
whether or not present pathologist numbers are adequate or,
if not, how many are needed – a question complicated by the
fact that many international pathologists migrate to the USA
in search of better salary or working conditions.
AN: Recruitment and retention are issues due to funding,
priority, and the stability of governments and supply chains.
MO: A UK-wide survey of histopathologists conducted in
2017 found that only 3 percent of histopathology departments
reported enough sta to meet clinical demand. Laboratory
sta are under pressure to provide slides, which should happen
within 24 hours, but regularly takes longer – in some places, up
to 10 days. is directly and detrimentally impacts patient care.
Taking a broader view, 95 percent of patients will have a
pathologist involved at some point in their healthcare journey.
Evidence points to pathology services constituting 2–4 percent
of the healthcare bill, meaning that the value of pathology
services far outweighs their cost.
Our workforce is an aging one; around one-third of UK
pathologists are 55 or over. When our most senior consultants
retire in the next ve to 10 years, there will not be enough trainees
to replace them in numbers, let alone in knowledge and expertise.
e COVID-19 pandemic brought into sharp relief the vital
need for pathology services. We must ensure that we learn
lessons to ensure that the global pathology community has
the resources it needs to help manage and mitigate the next
global health emergency.
What is the most important action we can take
today to ensure pathology’s future?
SR: e pathologist workforce in the hospital – and in local,
state, and national pathology societies – must remain strong and
provide the leadership and arguments to maintain good stang.
BM: First, raise awareness of the issue. Second, increase of the
number of residents in training. ird, heighten training ecacy
– and consider reducing timelines (for instance, in Germany, ve
years instead of six). Finally, implement digital assistance systems.
MW: Advocacy. Until policymakers and governments make
access to diagnostics a priority and provide the necessar y funding,
workforce challenges will not change. e lack of visibility of
diagnostics is the single most important barrier to increasing
the workforce; until it is addressed, little progress is possible.
JK: We need to rethink both pathologists’ training and the rules
governing pathology practice. We should explore the possibility of
train ing pathologists using dig ital slides, which wou ld greatly increase
the volume of pathology residents. We probably need to expand
the scope of training of pathologists’ assistants and cytologists. e
use of AI and assistive technology would be helpful increasing the
eciency of individual pathologists. Without increasing adoption
of technology, Africa will never close the diagnostic gap.
RB: Every university pathology laboratory should accept
pathology students on the condition of being trained in
histology procedures. Also, increase the number of histology
schools, both brick-and-mortar and online, to ensure the
necessary auxiliary personnel.
AN: Continued emphasis on providing accurate, accessible,
and on-time reporting of results. If pathology is an essential
component of patient care and there a re funds to pay sta, purchase
consumables, and maintain infrastructure, it will be successful.
Long-term, sustainable local (national) funding is needed.
MO: More training places for pathology specialties under
pressure, better IT systems and connectivity, and digital
pathology transformation programs.
We need to ensure that there are sucient training places
to meet future demand, so the College works closely with the
government and organizations responsible for creating training
places to ensure that pathology specialties are represented and
included in plans to improve the overall number of trainees. We
also need to attract medical undergraduates to take up pathology
as a career despite sti competition from other specialties. We
have invested in an active program of engagement to encourage
medical undergraduates to consider careers in pathology.
Digital pathology has the potential to improve patient care
and support the pathology workforce by making the diagnosis
and monitoring of disease much more ecient. In addition, it
facilitates high-quality teaching. We need more investment in
better IT for day-to-day work and to implement digital pathology
more widely so that sta can work more eciently and exibly.
Digital pathology, and developments in technology-enhanced
learning provide unique opportunities to support future training
models (attracting high-caliber trainees), multidisciplinary
learning, and new educational resource for trainees, practicing
pathologists, scientists, and those in pathology-linked roles.
Pathology services underpin health systems around the
world, but pathology is often overlooked. e global pathology
community has a critical role in raising awareness among
political leaders and policymakers to make the case for
pathology for the benet of patients.
Disclaimer: all data provided in this article are estimates. If you
would like to add to or amend the data provided in this article, please
contact Andrey Bychkov at bychkov.andrey@kameda.jp
See references online at:
tp.txp.to/0223/constant-demand
Download the raw data at:
tp.txp.to/worldwide/pathologist/data/pdf
Country Pathologists Year Path per 1M
Afghanistan 15 2021 < 1
Albania 22 2022 8
Algeria 400 2021 9
Angola 12 2012 < 1
Argentina 1235 2021 27
Armenia 40 2021 13
Australia 1924 2018 77
Austria 329 2022 36
Azerbaijan 30 2021 3
Bahrain 12 2022 7
Bangladesh 215 2020 1
Belarus 350 2021 37
Belgium 297 2015 26
Benin 13 2022 1
Bhutan 7 2021 9
Bolivia 150 2021 13
Bosnia 60 2021 18
Botswana 9 2022 4
Brazil 3500 2021 16
Bulgaria 80 2021 12
Burkina Faso 19 2022 1
Burundi 2 2022 < 1
Cambodia 8 2022 < 1
Cameroon 36 2022 1
Canada 1767 2017 48
Central African Republic 3 2022 1
Chad 2 2012 < 1
Chile 369 2021 19
China 11000 2020 8
Colombia 402 2021 8
Costa Rica 103 2022 20
Cote d’Ivoire 29 2022 1
Croatia 118 2021 29
Cuba 478 2019 42
Cyprus 34 2021 28
Czech 400 2021 37
Denmark 258 2021 44
Djibouti 3 2021 3
Dominican Republic 180 2022 16
DR Congo 45 2022 < 1
Ecuador 180 2021 10
Egypt 750 2021 7
El Salvador 60 2021 9
Eritrea 2 2022 1
Estonia 59 2015 45
Eswatini 0 2018 0
Ethiopia 125 2022 1
Fiji 5 2021 6
Finland 151 2019 27
France 1672 2020 26
Gabon 5 2022 2
Georgia 40 2021 10
Germany 1819 2021 22
Ghana 30 2012 1
Greece 150 2021 14
Guatemala 200 2022 11
Guinea 3 2022 < 1
Guyana 4 2022 5
Guyana 4 2022 5
Honduras 46 2022 5
Hong Kong 200 2020 27
Hungary 260 2021 27
Iceland 14 2022 41
India 20000 2021 14
Indonesia 733 2021 3
Iran 4248 2021 50
Iraq 250 2022 6
Ireland 218 2016 46
Israel 140 2021 16
Italy 1900 2020 31
Jamaica 35 2022 12
Japan 2642 2022 21
Jordan 60 2022 6
Kazakhstan 150 2021 8
Kenya 172 2022 3
Kiribati 1 2021 8
Kosovo 38 2022 19
Laos 8 2020 1
Latvia 36 2021 19
Lebanon 45 2020 7
Lesotho 2 2022 1
Liberia 2 2022 < 1
Liechtenstein 1 2022 26
Lithuania 90 2021 33
Luxembourg 22 2022 35
Macedonia 48 2022 23
Madagascar 18 2022 1
Malawi 9 2012 1
Malaysia 600 2022 18
Mali 18 2022 1
Malta 20 2022 45
Mauritania 5 2021 1
Mauritius 15 2012 12
Mexico 1700 2022 13
Moldova 60 2022 15
Mongolia 60 2019 18
Montenegro 17 2016 27
Morocco 350 2021 10
Mozambique 13 2021 < 1
Myanmar 500 2021 9
Namibia 5 2022 2
Nepal 288 2020 10
Netherlands 450 2022 26
New Zealand 280 2016 60
Nicaragua 130 2022 19
Niger 6 2022 < 1
Nigeria 300 2021 1
Norway 320 2020 59
Oman 50 2022 10
Pakistan 1500 2021 7
Palestine 23 2022 4
Panama 45 2021 10
Papua New Guinea 5 2021 1
Paraguay 50 2021 7
Peru 463 2022 14
Philippines 720 2021 7
Poland 783 2019 21
Portugal 200 2021 20
Puerto Rico 90 2022 32
Qatar 25 2021 9
Republic of Congo 4 2022 1
Romania 420 2021 22
Russia 3300 2020 23
Rwanda 8 2022 1
Samoa 1 2021 5
Saudi Arabia 269 2021 8
Senegal 35 2022 2
Serbia 180 2021 26
Sierra Leone 1 2012 < 1
Singapore 120 2020 21
Slovakia 110 2021 20
Slovenia 58 2015 28
Solomon Islands 1 2021 1
Somalia 2 2022 < 1
South Africa 750 2022 12
South Korea 1113 2020 22
South Sudan 2 2012 < 1
Spain 1450 2021 31
Sri Lanka 110 2021 5
Sudan 20 2022 < 1
Suriname 1 2022 2
Suriname 1 2022 1
Sweden 250 2021 25
Switzerland 265 2021 30
Syria 70 2022 4
Taiwan 600 2020 25
Tanzania 30 2022 < 1
Thailand 550 2021 8
Togo 10 2022 1
Tonga 1 2021 10
Tunisia 110 2022 9
Turkey 1640 2022 19
UAE 150 2021 15
Uganda 30 2022 1
UK 3900 2021 58
Ukraine 750 2019 17
Uruguay 100 2018 29
USA 21292 2019 65
Uzbekistan 132 2021 4
Vanuatu 1 2021 3
Venezuela 90 2022 3
Vietnam 600 2021 6
Zambia 8 2020 < 1
Zimbabwe 10 2018 1
